{"id":1728,"date":"2020-08-03T08:00:00","date_gmt":"2020-08-03T08:00:00","guid":{"rendered":"http:\/\/emultrasound.sdsc.edu\/?p=1728"},"modified":"2021-05-04T16:56:13","modified_gmt":"2021-05-04T16:56:13","slug":"checking-on-big-red","status":"publish","type":"post","link":"https:\/\/emultrasound.ucsd.edu\/index.php\/2020\/08\/03\/checking-on-big-red\/","title":{"rendered":"Case # 22: Abdominal Aortic Aneurysm"},"content":{"rendered":"
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A 72 year old male with known abdominal aortic aneurysm (5.7 cm s\/p fem-tib bypass, L AKA) presents for 3 weeks with diarrhea and mild LLQ pain. No nausea, vomiting, fever, back pain, urinary symptoms, or blood in stool. He has no localizing abdominal exam & no peritoneal signs, strong even radial pulses, and normal cardiopulmonary exam. On further chart review, patient is noted to have a 5+ cm aorta for the past 2 years, with the most recent CT scan a few weeks ago showing growth from 5.5 cm to 5.7 cm. An abdominal ultrasound is performed with the following findings.<\/p>\n

Vitals: <\/p>\n

T 98.7 HR 64 BP 167\/80 RR 18 O2 100%<\/p>\n

What are we concerned about for this patient and why? What is the interpretation of the abdominal ultrasound? What are the next steps for management in the ED?<\/p>\n

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Answer and Learning Points<\/h3>
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Answer: <\/span><\/strong><\/p>\n

The patient\u2019s presenting complaints (diarrhea, mild abdominal pain) do not coincide with the classic triad of ruptured AAA (hypotension, back pain, pulsatile abdominal mass). In addition, this patient is hemodynamically stable and comfortable, which is reassuring. However, ruptured AAA can have a wide variety of presentations and should always be considered in patients with known large AAA. In addition, this patient had a known AAA >5 cm for the past two years with poor vascular surgery follow-up, and the risk for rupture for AAA\u2019s 5.0-5.9cm increases by 5-10% each year. (1)<\/span><\/p>\n

As this patient recently had a CT scan a few weeks ago revealing large, stable AAA, the decision was made to investigate via ultrasound rather than undergo more radiation from CT. Ultrasound is also highly sensitive and specific for detecting AAA. (2) The above images show the AAA has a large intramural thrombus with no evidence of leaking fluid nor dissection flap. The AAA is stable, measuring a similar width of 5.7 cm. The clinician can investigate further by doing a RUSH exam to reassure against intraperitoneal bleeding and other types of shock. Elective aortic surgery is recommended for patients with AAA >5.5 cm, because at this threshold the risk of rupture is greater than risk of surgery, therefore it is reasonable to consult vascular surgery for this patient in the ED. (1)<\/span><\/p>\n

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Learning Points<\/span><\/strong><\/p>\n